Bilateral Lower Extremity Edema Research Articles

8233 Cushing Disease Presenting As Severe Persistent Hypokalemia

Abstract Disclosure: G. Palaguachi: None. A. Randhawa: None. M. Sattar: None. G. Mahajan: None. J. Karam: None. Introduction: The clinical presentation of Cushing Disease represents a wide spectrum of clinical and laboratory findings, including electrolyte derangements such as hypokalemia. In this case report, we describe a patient in whom the admission for severe persistent hypokalemia prompted the diagnosis of Cushing Disease. Clinical Case: A 35-year-old woman with history of type 2 diabetes, hypertension, and hyperlipidemia, presented to the Emergency Department with worsening bilateral lower extremities swelling, impairing her ability to walk, found to have severe hypokalemia with K level of 2.8 (3.4-4.8 mmol/L), in additional to right pubic rami fracture, left breast abscess, oral thrush, and severe hyperglycemia with HbA1C of 15.4%. Additional history was relevant for hirsutism, scalp hair thinning, weight gain, and amenorrhea of few months duration. Physical examination was significant for round face, thin scalp hair, oral thrush, facial hirsutism, central obesity, wide abdominal striae, onychomycosis, thin skin with multiple ecchymoses, bilateral lower extremity edema, and thin extremities. Her hypokalemia was resistant to therapy and K level remained in 3.2-3.5 mmol/L range on the third week of admission despite oral and intravenous potassium replacements and spironolactone high dose therapy at 100mg twice a day. Additional laboratory testing showed Cortisol 25.0 (6.70 - 27.60 ug/dL) and normal Aldosterone and renin levels. Given absence of otherwise clear etiology of hypokalemia, and presence of multiple features of Cushing’s syndrome, further inpatient evaluation included 24-hour Urine Free Cortisol level that came back at 2754 (3.5 - 45.0 mcg/24hour), 1 mg Dexamethasone Suppression Test Cortisol of 24.9 (6.70 - 27.60 ug/dL), ACTH of 151.0 (7.2 - 63.3 pg/mL), and 8 mg Dexamethasone Suppression Test Cortisol of 14.2 (6.70 - 27.60 ug/dL). MRI Pituitary showed a pituitary adenoma (0.7 x 0.3 cm) with cavernous sinus involvement. A diagnosis of Cushing disease was made and the patient underwent transsphenoidal surgery on the fourth week of hospital stay with diffuse ACTH staining of the tumor. Postoperatively, cortisol levels were not suppressed suggesting persistent disease, but hypokalemia resolved while on Spironolactone. Conclusion: This patient had several classical features of hypercortisolemia with associated hyperglycemia, recurrent infections, and bone fractures, however the finding that connected the dots and prompted establishing her diagnosis was her severe refractory hypokalemia. Although not a defining feature of Cushing Disease, and usually more pronounced with ectopic ACTH secretion, severe and/or persistent hypokalemia can be part of the presenting symptoms. This case demonstrates the importance of including Cushing Disease as part of the differential diagnosis of persistent hypokalemia in correlation with other clinical signs and diagnostics. Presentation: 6/2/2024

8269 Euglycemic Diabetic Ketoacidosis Secondary to Rapid Weight Loss in a Patient on Dapagliflozin

Abstract Disclosure: A. Sridhar: None. A. Iqbal: None. A. Prabha Kumar: None. F. Haider: None. M. Babic: None. Background: Euglycemic DKA (eDKA) is a potentially life-threatening complication in patients taking SGLT 2 inhibitors (SGLT2i). Common precipitating factors include strenuous exercise, carbohydrate restriction, starvation, and alcohol use. Clinical case: The patient is a 71-year-old female with past medical history of Type 2 diabetes mellitus (DM), gastro-esophageal reflux disease, hypertension, hyperlipidemia, coronary artery disease and chronic pain syndrome. She presented with complaints of nausea, vomiting, reduced appetite and generalized weakness for the past 4 days. She also reported an intentional weight loss of 35 pounds in the last 6 weeks achieved with daily exercise and a carbohydrate restricted diet. She had been taking Dapagliflozin-Metformin 5-1000 mg twice daily and pioglitazone 30 mg once daily for 2 years and Ozempic subcutaneous injection 1 mg weekly for 6 months. Physical examination in the ED showed normal vital signs, dry mucous membranes, and trace bilateral lower extremity edema. Blood work was significant for venous blood gas pH 7.24, bicarbonate 9 mmol/L, anion gap 30 mmol/L, blood glucose 94 mg/dL, HbA1c 5.8 % and WBC 13.2 K/uL. Urinalysis was positive for glucose and ketones. The patient was admitted for management of eDKA and was started on intravenous 10% dextrose infusion and insulin infusion. Endocrinology was consulted and they recommended following DKA protocol and stopping Dapagliflozin at discharge. She was maintained on insulin infusion for 48 hours after which her anion gap normalized, and she was transitioned to subcutaneous insulin with Lantus 8 units and sliding scale insulin. During this time the patient’s symptoms resolved, and she was able to tolerate oral diet. She eventually resumed her home medications with oral Metformin 1000 mg twice daily and pioglitazone 30 mg once daily. Dapagliflozin and Ozempic were discontinued at discharge. Strenuous exercise and carbohydrate restriction which caused rapid weight loss, were likely the triggers for eDKA in our patient. A diabetes educator was involved at discharge and the patient was counseled to avoid possible triggers and identify warning signs and symptoms in the future. The patient was discharged with a follow up appointment with her Endocrinologist. Conclusion: High index of clinical suspicion is important to promptly diagnose eDKA in patients taking SGLT2i. Patient education on avoiding precipitating factors and early recognition of signs and symptoms is necessary to reduce mortality. Presentation: 6/3/2024

7743 A Case Study of Ectopic Adrenocorticotropic Hormone Secretion from Pancreatic Neuroendocrine Tumor

Abstract Disclosure: K.S. Wei: None. J. Huang: None. Introduction: Pancreatic neuroendocrine tumors (PanNETs) are uncommon cancers that account for less than 2% of pancreatic malignancies. Even rarer are ACTH-producing NETs which may only become symptomatic until after metastasis. This case study examines the distinct presentation and diagnostic complexities associated with ectopic adrenocorticotropic hormone (ACTH) secretion from a PanNET. Clinical Case:A 42 year-old male with hypertension and type 2 diabetes initially presented to the hospital with increased abdominal girth for one month, bilateral lower extremity edema for two weeks, and generalized abdominal pain. He had unremarkable surgical, family, and social histories. Patient was afebrile, normotensive, saturating well on room air, with exam notable for a distended abdomen and 2+ bilateral pitting edema. Admission labs were notable for potassium of 2.4 (ref: 3.5-5.1 mmol/L). MRI abdomen showed hepatomegaly with numerous heterogeneously enhancing masses and an ill-defined pancreatic tail mass with involvement of the spleen. Liver biopsy showed well-differentiated neuroendocrine tumor, grade 2. He was started on octreotide 20mg q4weeks and capecitabine/temozolomide q4weeks. Two months later, the patient was readmitted after presenting with back pain for two days, found to have acute compression fractures of T9-L1 without spinal PET activity. At follow-up visit with endocrinology, he endorsed easy bruising and muscle weakness and had hypertension (161/96 mmHg) with hypokalemia. Random cortisol was 43.7 (ref: 2.5-11.9 mcg/dL). ACTH was 124 (ref: 6-50 pg/mL) despite receiving chemotherapy. 24-hour urine cortisol was 3,049 (ref: 4-50 mcg/24 hrs). He was diagnosed with ectopic Cushing’s disease from ACTH-producing PanNET leading to osteoporosis and fracture of the vertebral bodies. For the ectopic Cushing’s disease, he was started on ketoconazole 200mg BID with plan to start osilodrostat once approved. For the fracture, he is scheduled for Zometa infusion and IR kyphoplasty. Conclusion: This case offers several important clinical insights. In patients with PanNET with Cushingoid exam findings, ACTH-producing PanNET should be high on the differential. Most ACTH NETs are aggressive often with liver metastases, whereby metastatic disease will have already occurred by the time the Cushingoid features develop. The initial severe hypokalemia and hypertension should have prompted investigation for mineralocorticoid excess from hypercortisolism, which may have led to an earlier diagnosis of ectopic ACTH Cushing’s disease, thereby decreasing the possibility of developing vertebral fractures, uncontrolled diabetes and hypertension. Ketoconazole or osilodrostat may be used to treat Cushing’s disease from ACTH NETs. Presentation: 6/1/2024

Diagnosis and treatment of secondary nephrotic syndrome with rash as the first symptom: a case report

BackgroundMembranous nephropathy (MN) is a common type of nephrotic syndrome (NS) in adults, accounting for about 20–30% of cases. Although secondary to specific factors, the coexistence of MN and mantle cell lymphoma (MCL) has been scarcely reported in clinical literature.Case presentationA 59-year-old Chinese male was admitted to the hospital with a generalized pruritic rash with bilateral lower extremity edema, which did not improve significantly after symptomatic treatment. He had undergone renal biopsy, and the diagnosis was thought to be secondary MN (SMN), therefore, we did a lymph node biopsy on the patient and found that MN was complicated with MCL. Soon after, the patient was admitted to the hematology department for a BR chemotherapy regimen (composed of bendamustine 90 mg/m2 BSA (body surface area), rituximab 375 mg/m2 BSA and dexamethasone 5 mg), and during the post-treatment follow-up, both his symptoms and renal function improved.ConclusionsThe mechanism underlying the combination of SMN and MCL remains elusive and exceedingly rare, consequently often overlooked in clinical practice. This case serves to offer valuable clinical insights for diagnosis and treatment, while emphasizing the pivotal role of renal pathology in clinical assessment.

Ketamine induced acute systolic heart failure

Background: Studies have shown major cardiovascular effects associated with ketamine use disorder including dose-dependent negative inotropic effects. Preoperative ketamine use has been linked to ketamine-induced stress cardiomyopathy. Case presentation: A 28-year-old female with a history of recurrent cystitis and ketamine use disorder (twice weekly for 14 years) presented with bilateral lower extremity oedema and shortness of breath for 3 months. She was tachycardic with a troponin level of 0.07 ng/ml and a B-type natriuretic peptide (BNP) level of 2511 pg/ml. Electrocardiogram showed normal sinus rhythm and transthoracic echocardiography (TTE) showed left ventricular ejection fraction (EF) of 15%, dilated left ventricle, and severe tricuspid and mitral regurgitation. Computed tomography (CT) scan of the chest and abdomen showed bilateral pleural effusions with congestive hepatopathy and ascites. The patient was started on intravenous furosemide, metoprolol, and sacubitril/valsartan. Rheumatological workup including complement levels, and antinuclear anti-double-stranded DNA was negative. A repeat TTE 2 weeks later revealed an EF of 25% and moderate tricuspid regurgitation. Four months later, the EF was 54% with normal left ventricular cavity size. Conclusion: Although ketamine use disorder is increasing, data on long-term side effects is minimal. Screening for ketamine use disorders should be considered in patients presenting with acute systolic heart failure. Long-term studies are needed to evaluate the benefits of adding ketamine screening to standard urine toxicology.

Heyde Syndrome as Cause of New-onset Heart Failure in the Setting of Bioprosthetic Aortic Valve: A Case Report

This report describes the case of a 70-year-old female with a history of bioprosthetic aortic valve replacement. She presented to the emergency department with significant shortness of breath and bilateral lower extremity edema, which was found to be secondary to new-onset acute symptomatic congestive heart failure in the setting of Heyde syndrome.

Abstract 12450: Mystifying Masquerade: Renal Cell Carcinoma Associated Arteriovenous Fistula Presenting as High-Output Heart Failure

Case Presentation: 59 year-old woman with CKD stage 3b and hypertension presented with 3 months of progressive dyspnea, abdominal distension, bilateral lower extremity edema, and a 60-pound weight gain. Physical exam noted diffuse anasarca, with stable hemodynamics on room air. EKG revealed low voltage leads and chest X-ray demonstrated an enlarged cardiac silhouette. CT abdomen was remarkable for significant ascites, body wall edema, and a suspicious large right renal mass. Diagnostic paracentesis indicated cardiac ascites. Echocardiogram showed preserved ejection fraction, moderate pericardial effusion and an enlarged right side of the heart. Right heart catheterization confirmed high-output heart failure (HOHF). A suspected renal mass-related arteriovenous fistula (AVF) was confirmed through inferior vena caval and renal venogram blood gas sampling, indicating arteriovenous shunting within the renal mass. Hepatic venogram excluded portal hypertension. MRI abdomen confirmed a large necrotic right renal mass consistent with renal cell carcinoma (RCC). Symptoms significantly improved after nephrectomy, with aggressive diuresis, and therapeutic paracenteses leading to an 80-pound weight loss. Postoperative echocardiography illustrated decrease in pericardial effusion and right ventricular size. Cardiac MRI and stress test were unremarkable prior to planned immunotherapy for stage III RCC. Discussion: AVF and HOHF associated with malignancy are unusual presentations. RCC is the most prevalent underlying malignancy linked with AVF and is hypothesized to be a result of hypervascularity caused by a VHL gene mutation. The most often utilized imaging modalities for detecting a tumor-related AVF are contrast enhanced CT or MRI. When imaging is inconclusive, a venogram with blood gas sample, as observed in our case, may be considered to establish an RCC-associated AVF.

Abstract 17328: A Case of Reversible Severe Systolic Cardiomyopathy; Thinking Outside the Box

Introduction: Non-ischemic systolic cardiomyopathy is associated with significant morbidity and mortality. Prompt evaluation and timely removal of the potential insult may lead to reverse remodeling and recovery of the left ventricular (LV) systolic function. Case: A 39-year-old female with BMI 40 presented with dyspnea and bilateral lower extremity edema. Vital signs significant for mild tachycardia and hypertension. ECG showed sinus tachycardia. Physical exam revealed bibasilar crackles and 3+ pitting edema of the lower extremities. Laboratory significant for NTpro BNP 563 pg/dL and TSH <0.005 IU/mL with a free T4 of 2.73 ng/dL. Chest x-ray showed pulmonary vascular congestion. Echocardiogram showed severely reduced LV systolic function with ejection fraction (EF) of 27%, global LV hypokinesis and diastolic LV diameter of 6.85 cm. No significant atrial or ventricular arrhythmias noted on Telemetry. A CT angiography of the coronary arteries showed no evidence of calcification or obstructive coronary disease. Additional labs revealed severely elevated TSH receptor antibody and thyroid stimulating immunoglobulin. Diffuse thyroid enlargement noted on ultrasound. Patient was diagnosed with Grave’s disease (GD) with Burch-Wartofsky score of 30 indicating an impending thyroid storm. She was treated with Metoprolol and Methimazole. She underwent intravenous diuresis and was started on guideline-directed medical therapy for systolic cardiomyopathy. In follow-up after 6 months, her TSH had normalized. On repeat imaging, her LVEF improved to > 50% with diastolic LV diameter of 5.6 cm. Discussion: This patient was diagnosed with non-ischemic dilated systolic cardiomyopathy due to severe hyperthyroidism from GD. Thyrotoxicosis-induced systolic cardiomyopathy occurs in about 1% of patients with GD and is associated with increased morbidity and mortality. Excess thyroid hormones in thyrotoxicosis can affect multiple regulatory and structural genes of cardiac myocytes resulting in abnormal intracellular calcium regulation and impaired LV systolic and diastolic function. Our experience is consistent with literature demonstrating the importance of timely diagnosis and treatment of this reversible cause of systolic cardiomyopathy.

The Relationship Between the Presence of Distal Collateral Lymphatic Flows and Obesity in Patients with Bilateral Lower Extremity Edema

Objective: This study aimed to comprehensively assess radionuclide imaging findings to aid in the clinical diagnosis of early-stage lower extremity lymphedema. Methods: Our retrospective study included 135 patients who underwent lymphoscintigraphy for bilateral lower extremity edema (BLEE) between 2017 and 2022. Of these patients, 117 (86.7%) were female. Lymphoscintigraphic images were acquired at the 10th, 40th, and 2nd hours post-injection of radiopharmaceuticals. Bilateral lower extremity lymphatic congestion (MLC) was observed in the 2nd-hour images of radionuclide imaging (RI), with an associated accumulation of activity in the inguinal lymph nodes. All patients presented with lower extremity edema. Results: Among our patients, 55 (40.7%) were classified as obese. Bilateral distal collateral flows (BDCF) were identified in 60 (44.4%) of our patients, all of whom were female. Within this group, 13 (21.7%) were obese, and 11 (18.3%) exhibited distal and direct muscle lymphatic congestion (DDMLC). DDMLC was present in 63 (46.7%) patients. Unilateral distal collateral flow (UDCF) was detected in 75 (55.6%) of the patients with BLEE, with 67 (89.3%) of them being obese. Obese patients exhibited a significantly higher prevalence of both UDCF and DDMLC (p: 0.0005). Detailed results can be found in Table 1-4 and Figures 3 and 4. Conclusion: Functional bilateral radionuclide imaging methods provide valuable data for physicians, enabling bilateral and comparative assessments. However, particular attention should be paid to the interpretation of asymmetric images, especially in specific patient groups.

FRI204 A Rare Case Of Cushing Syndrome In Pregnancy: Diagnosis And Therapeutic Challenges

Abstract Disclosure: Z. Cardona: None. E.D. Szmuilowicz: None. Introduction: Cushing’s syndrome (CS) rarely occurs during pregnancy, and diagnosis of Cushing’s syndrome in pregnancy is challenging due to physiologic changes during gestation. CS is associated with severe maternal and fetal complications. Clinical Case: A 36-year-old woman presented at 21 weeks gestational age with a known adrenal nodule admitted for evaluation of HTN, bilateral lower extremity edema, transaminitis, hyperglycemia, and acute hypoxemic respiratory failure. Reported proximal muscle weakness, facial swelling, anxiety, depression, perspiration, and headaches associated with HTN. Physical exam notable for mild supraclavicular fat deposition, chest and neck plethora, hypertrichosis, and bruising. CT abdomen pelvis revealed a 2.3-cm left adrenal nodule measuring 30 Hounsfield units. Biochemical evaluation included a plasma renin activity of 0.719 ng/mL/h [ref range: 0.167-5.380 ng/mL/h], aldosterone <1.0 ng/dL [ref range: 0.167-5.380 ng/dL], potassium 2.6 mEq/dL, free plasma metanephrines (MN) < 25 pg/mL [ref range: < or = 57 pg/mL], free normetanephrines (NMN) < 25 pg/mL [ref range: < or = 148 pg/mL, total free MN and NMN < 25 [ref range: < or = 205 pg/mL]. 24-hour urine free cortisol (UFC) was markedly elevated at 1854.1 mcg/24h [ref range: 3.1-50.0 mcg/24h], repeat 2186.2 mcg/24h, ACTH: 1.5 pg/mL [ref range: 7.2-63.6 pg/mL], confirming a diagnosis of ACTH-independent CS. Her case was complicated due to the adrenal nodule location. Patients with left adrenal nodules are at risk of developing inferior vena cava (IVC) syndrome during left adrenalectomies, especially in the third trimester, due to compression exerted by the uterus while lying on the right side during the procedure. She underwent an uncomplicated laparoscopic left adrenalectomy. Was started on hydrocortisone (HC) following surgery. There was concern for transient neonatal adrenal insufficiency at delivery. Measuring adrenal insufficiency in utero is challenging; however, estriol could serve as a surrogate marker of fetal adrenal function. Her estriol was normal, possibly indicating intact fetal adrenal activity. She had an uncomplicated vaginal delivery with no signs of adrenal insufficiency in her baby. Interestingly, she had a severely low alkaline phosphatase (ALP) which completely normalized soon after adrenalectomy. Clinical Lesson: This case depicts the challenges in managing CS in pregnancy and its repercussions regarding maternal, fetal, and delivery outcomes. Additionally, it highlights the importance of implementing a multidisciplinary approach, including obstetricians, endocrinologists, endocrine surgeons, and pediatricians, to ensure the optimization of therapeutic strategies. Presentation: Friday, June 16, 2023

THU013 A Rare Case of Ectopic Cushing’s Syndrome Caused By Metastatic Parotid Gland Carcinoma

Abstract Disclosure: E. Punni: None. I. Goyal: None. Introduction: Ectopic Cushing’s Syndrome (ECS) is a rare condition that accounts for only a small percentage of all Cushing’s syndrome cases. Although rare, the typical tumors associated with ECS are small cell lung carcinomas, bronchial carcinoids, pancreatic neuroendocrine tumors, medullary thyroid carcinomas, thymic carcinoids and pheochromocytomas. Metastatic acinic cell carcinoma (ACC) of the parotid gland has very rarely been associated with ectopic Cushing’s syndrome. Case Presentation: A 67-year-old Caucasian male with a known diagnosis of high grade metastatic ACC of the parotid gland presented to the hospital with progressively worsening proximal muscle weakness and bilateral lower extremity edema of 6 weeks duration. A month prior to presentation, he developed persistent hypokalemia requiring potassium supplementation and was diagnosed with new onset type 2 diabetes mellitus. Laboratory results on admission were remarkable for low potassium at 2.5 mEq/L (N: 3.5-5.3 meq/L), a random cortisol level of 107 mcg/dL (N: 6 - 30 mcg/dL), and an ACTH level of 485 pg/mL (N: 7.2 - 63.3 pg/mL). Subsequently, a 24-hour urine cortisol was > 1600 ug/24 hours (N 5-64 ug/24 hours). A 1 mg dexamethasone suppression test failed to suppress an 8 a.m. cortisol with level of 110.8 mcg/dl (N < 1.8 mcg/dl). Following, an 8 mg dexamethasone suppression test also failed to suppress 8 a.m. cortisol with a value of 100.8 mcg/dl. A MRI of the pituitary with and without contrast showed mild diffuse enlargement of the pituitary gland concerning for pituitary hyperplasia. At the time, ECS was highly suspected given the rapid course of patient’s presentation, known metastatic malignancy, and failed 8 mg dexamethasone suppression test. An inferior petrosal sinus sampling (IPSS) could not be performed given the patient’s guarded condition. Instead, a PET/CT Ga-68 DOTA-TATE scan obtained showed widespread DOTA-TATE avid malignancy concerning for neuroendocrine type tumor. Patient was a poor surgical candidate, therefore bilateral adrenalectomy could not be performed for the rapid treatment of ECS. Patient was started on a steroidogenesis inhibitor ketoconazole. However, he elected to undergo hospice care and passed away shortly after. Conclusion: This case is particularly interesting given that metastatic ACC of the parotid gland causing ECS is rare with only a few cases reported in the literature. This case highlights the importance of maintaining a high degree of suspicion for diagnosing ECS especially when patients present with rapid onset of signs and symptoms of Cushing’s syndrome and a known underlying malignancy. Recognizing less common causes of ECS may prompt early diagnosis and intervention. Presentation: Thursday, June 15, 2023

SAT484 High Degree AV Block And Sinus Arrest: Cardiovascular Manifestations Of Myxedema Coma

Abstract Disclosure: J. Bosques-Lorenzo: None. P. Rivera: None. J. Colon-Castellano: None. Y. Otero-Dominguez: None. Bosques-Lorenzo Jaymilitte, Rivera-Cariño Patricia, Colon-Castellano Janet, Otero-Dominguez Yomaira. Background: Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. The most common presenting symptoms are altered mentation, hypothermia, edema, and respiratory depression. The cardiovascular system is often involved, in the form of sick sinus syndrome, bradycardia, low voltage QRS complex, QT prolongation, and rarely cardiac arrest. Here we present a case of myxedema coma complicated with high degree AV block and sinus arrest. Clinical Case: A 84 year-old man with history of hypothyroidism on levothyroxine 125 mcg, presented to the ER due to disorientation, bilateral leg edema, and abdominal discomfort for 3 days. Vital signs revealed a temperature of 97.5 F, HR of 60bpm, BP 174/88 mmHg, and oxygen saturation of 100% at room air. Physical exam was pertinent for bilateral lower extremity edema, facial puffiness, macroglossia, slow mentation, and scattered rales on lung auscultation. Laboratories showed an elevated TSH (296.8 uIU/mL), with low total T3 and free T4 (45.03 ng/dL and 0.228 ng/dL respectively) with a myxedema score of 45. Altered renal parameters as per BUN and creatinine levels (83.4 mg/dL and 5.75 mg/dL) without electrolytes disturbances and elevated CPK (1250 U/L). Infectious process was ruled out. Chest X-ray showed vascular congestion. Echocardiogram showed a small pericardial effusion. Patient was admitted to ICU and started on IV Levothyroxine, along with hydrocortisone. Liothyronine was initially not available. On second admission day, the patient developed hypothermia (94.3 F) which was managed with passive warming. Telemetry monitoring recorded multiple episodes of bradycardia raging from 30 to 50 bpm, high-degree AV block, and one episode of sinus arrest of 15 seconds with self-resolution. Altered mentation persisted for which endotracheal intubation was performed to secure airway. A temporary transvenous pacing was placed emergently. Levothyroxine dose was further adjusted and liothyronine was initiated. After a few days of treatment, patient demonstrated clinical improvement that was supported with follow up thyroid function test. Patient was extubated and transitioned to oral levothyroxine. Nevertheless, he remained dependent of transvenous pacing for which permanent pacemaker placement was coordinated. Conclusion: Cardiovascular complications in myxedema coma are associated with poor prognosis with a mortality approaching 80%. Few cases of sinus or cardiac arrest associated to Myxedema coma have been reported in the literature. In this case, the patient developed high-degree AV block with concomitant sinus arrest despite prompt initiation of intravenous thyroid hormone. Prompt identification of cardiovascular involvement can prevent cardiovascular morbidity and mortality in myxedema coma. Presentation Date: Saturday, June 17, 2023

Chylous ascites associated with primary pulmonary hypertension: A case report and literature review

Chylous ascites is a rare condition that results from the accumulation of lymph in the abdominal cavity through a variety of mechanisms. We hereby report a case of chylous ascites in a 67-year-old woman who was admitted to our hospital with abdominal distension, bilateral lower extremity edema, and shortness of breath on exertion. The patient had a long history of primary pulmonary hypertension, cor pulmonale, and diabetes mellitus. Imaging studies revealed massive peritoneal fluid, which, after drainage, was found to be consistent with chylous ascites. The patient received high doses of diuretics with a marked improvement in symptoms over the following days. There was no reaccumulation of ascites by the time of discharge. To the best of our knowledge, there are few cases in the literature where chylous ascites has been reported in association with primary pulmonary hypertension.

Evaluation of Interstitium by Lymphatic Uptake Method in Chronic Bilateral Lower Extremity Edema.

Symmetrical bilateral lower extremity edema (BLEE) needs to be treated effectively. Finding the cause of this condition increases the success of treatment. Fluid increase in the interstitial space (FIIS) is always present as a cause or a result. Subcutaneously administered nanocolloid is transported by uptake by lymphatic pre-collectors, and this uptake takes place in the interstitium. We aimed to evaluate the interstitium with labeled nanocolloid and contribute to the differential diagnosis in cases with BLEE. Our retrospective study included 74 female patients who underwent lymphoscintigraphy for bilateral lower extremity edema. Technetium 99m (Tc-99m) albumin colloid (nanocolloid), a marked colloidal suspension, was applied subcutaneously to two different areas on the dorsum of both feet with a 26 gauge needle The dose volume administered intradermally is approximately 0.2-0.3 ml, and each injector has 22-25MBq of activity. Siemens E-Cam dual-headed SPECT gamma camera was used for imaging. Dynamic and scanning images were taken with a high-resolution parallel hole collimator. Ankle images were re-evaluated by two nuclear medicine specialists, independent of physical examination and scintigraphy findings. 74 female patients with bilateral lower extremity edema were divided into two groups based on physical examination and lymphoscintigraphy findings. There were 40 and 34 patients in Groups I and II, respectively. In the physical examination, patients in Group I were evaluated as lymphedema, and patients in Group II were evaluated as lipedema. The main lymphatic channel (MLC) was not observed in any of the patients in Group I in the early images, and the MLC was observed at a low level in the late imaging in 12 patients. The sensitivity of the presence of distal collateral flows (DCF) in the presence of significant MLC in early imaging in demonstrating increased fluid in the interstitial space (FIIS) was calculated as 80%, specificity as 80%, PPV 80%, and NPV 84%. While MLC is present in early images, concomitant DCF occurs in cases of lipoedema. The transport of increased lymph fluid production in this group of patients can be covered by the existing MLC. Although MLC is evident, the presence of significant DCF supports the presence of lipedema. It can be used as an important parameter in the diagnosis in early cases where physical examination findings are not evident.

Bilateral Lower Extremity Edema of a Woman Aged 59 Years

<p>有許多病因會造成雙下肢水腫，心臟、肝臟、腎臟等相關疾病首先需被排除。本案例為一位罹患甲狀腺亢進的59歲女性、規則服用丙硫氧嘧啶（Propylthiouracil, PTU）兩年，以雙下肢水腫為最初表現，伴隨有血尿、蛋白尿及腎功能損傷，初始臆測是不明原因的腎絲球腎炎，經檢驗發現抗嗜中性球細胞質抗體（Antineutrophil Cytoplasmic Autoantibodies, ANCA）呈陽性反應， 最終透過腎臟切片，證實為PTU相關ANCA血管炎，予以停止PTU、給予類固醇治療後，腎功能獲得改善。針對此類個案無法以症狀及檢驗檢查確立診斷時，需安排被侵犯部位的切片檢查來協助診斷，當確定是藥物相關ANCA血管炎時， 應立即停藥，避免造成致命性的傷害。</p> <p> </p><p>Many diseases may cause bilateral lower extremity edema. Diseases related to the heart, liver, and kidney shall be excluded first. The case of this study was a women aged 59 years with hyperthyroid­ism. The patient regularly took propylthiouracil (PTU) for 2 years. Bilateral lower extremity edema emerged as the first symptom, followed by hematuria, proteinuria, and impaired kidney functions. Initially, the medical team assumed the cause was glomerulonephritis with an unknown cause. After examination, the team discovered the patient was antineutrophil cytoplasmic autoantibodies (ANCA) positive. Through kidney biopsy, the team confirmed that the cause was PTU-related ANCA vascu­litis. Therefore the delivery of PTU was discontinued, and steroid treatment was administered. The patient’s kidney functions gradually improved. In similar cases where diagnosis cannot be confirmed through symptom interpretations or general examinations, biopsy of the infected area should be per­formed to confirm the diagnosis of the cause. When drug-related ANCA vasculitis is confirmed, the delivery of medicine must be suspended immediately to avoid further lethal damage.</p> <p> </p>

P177 COR TRIATRIATUM DEXTER: THE ROLE OF TRANSTHORACIC ECHOCARDIOGRAPHY

Abstract Introduction Cor triatriatum dexter (CTD) is an extremely rare congenital cardiac abnormality and its prompt recognition by transthoracic echocardiography (TTE) is essential for a correct diagnosis. Case presentation An 82–years–old woman was admitted to our cardiologic ward for worsening dyspnoea. The physical examination revealed a bilateral lower extremity oedema with elevated jugular venous pressure and hepatomegaly. The ECG showed atrial fibrillation with a heart rate of 70 bpm already treated with beta–blockers and direct–acting oral anticoagulant. TTE revealed a left ventricle with normal dimensions and function, a dilated right ventricle with a mild systolic dysfunction and increased wall thickness, a marked dilation of the right atrium and a tricuspid severe regurgitation. A deeper analysis of the right atrium revealed the presence of membrane partitioning the chamber into two compartments (Figure 1). The separation was incomplete as demonstrated by the flow across the membrane with Color–Doppler technique (Figure 2). The patient was treated using high doses of diuretics with a subsequent clinical improvement. A percutaneous intervention on the tricuspid valve was planned by the Heart Time. Discussion CTD derives from the persistence of the right valve of the sinus venosus resulting in a complete or incomplete fibromuscular band which separates the right atrium into two cavities. The spectrum of clinical manifestations is broad, based upon the degree of separation. In older patients CTD is often asymptomatic and incidentally found during diagnostic imaging examinations. TTE plays a key role in the identification of CTD, as a first–line diagnostic imaging tool. It, also, allows a differential diagnosis with a prominent eustachian valve, chiari network, and thebesian valve. However, in difficult cases a multiparametric approach is required including transoesophageal echocardiogram or cardiac magnetic resonance. Echocardiography has a pivotal role in the prompt recognition of other cardiac abnormalities associated with CTD such as atrial septal defect or patent foramen ovale, right ventricular hypoplasia and Ebstein’s anomaly. In our case, none of these were documented. Atrial fibrillation should be investigated due to severe atrial chamber dilation. A multiplane evaluation of the right atrium and the Color–Doppler technique are helpful to visualize the configuration of the membrane and evaluate the absence of flow disturbances.

The utility of computed tomography venography in the routine evaluation of patients who present to a lymphedema center with lower extremity edema

ObjectiveComputed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO. MethodsWe retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings. ResultsOf the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients). ConclusionsSix percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.

Abstract #1404146: The Ups and Downs of Diagnosing Insulinoma

Insulinomas are rare neuroendocrine tumors of the pancreas. The diagnosis of an insulinoma may be delayed in the geriatric population, as older individuals often have comorbid conditions making evaluation more difficult. The case described here involves an exceptionally rare presentation of insulinoma in a 78-year-old male with underlying type 2 diabetes mellitus and heart failure. A 78-year-old man with a past medical history of type 2 diabetes, heart failure, and chronic kidney disease presented to the hospital with bilateral lower extremity edema and shortness of breath. He had been hospitalized four times during the previous six months for acute heart failure exacerbations accompanied by recurrent episodes of hypoglycemia. Of note, his diabetes was well-controlled with glimepiride and dapagliflozin only. The patient reported symptomatic hypoglycemia, primarily during fasting episodes, with nadir serum glucose values between 40 and 50 mg/dL. During hospitalizations, total insulin (range 22-68 uU/mL), and C peptide (range 6.9-16.4 ng/mL) concentrations were inappropriately elevated when glucose was low, indicative of endogenous hyperinsulinemia. However, this hypoglycemia was thought to be secondary to recent sulfonylurea use in the setting of poor diet and acute renal insufficiency related to heart failure. Both glimepiride and dapagliflozin were held, though he inadvertently continued to take glimepiride until his fourth hospitalization. During his fourth admission, the patient continued to have symptomatic hypoglycemia. As his sulfonylurea screen was negative, he underwent an Octreoscan that revealed radiotracer uptake in the distal pancreas. An endoscopic ultrasound with biopsy revealed a well-differentiated neuroendocrine tumor of the pancreas. His heart failure made agents such as diazoxide, verapamil, and phenytoin undesirable, and he was discharged on subcutaneous octreotide three times daily with a plan to follow up in the surgery clinic. The presentation of insulinomas in the geriatric population can be variable and nonspecific, increasing the risk of misdiagnosis or delay of diagnosis. Missing the diagnosis can lead to increased morbidity and mortality via cognitive impairment and falls. Our patient experienced a delay in diagnosis of insulinoma of over one year despite satisfying the criteria of Whipple’s triad during his first admission. The patient had been asked to stop all anti-diabetic medications during his third admission. However, he misunderstood and continued glimepiride. Further, his acute renal insufficiency, heart failure, and decreased appetite provided alternative causes for his hypoglycemia. Insulinomas are extremely rare pancreatic neuroendocrine tumors that typically present in patients between 40 and 60 years of age. However, there have been reports of these rare tumors in older individuals, who often have comorbid conditions making their diagnosis more difficult. This case report highlights the importance of including insulinoma as a cause of persistent endogenous hypoglycemia among the geriatric population.

56-Year-Old Woman With Bilateral Lower Extremity Edema

A 56-year-old woman presented to the primary care clinic for evaluation of a 2-year history of bilateral lower extremity edema. She denied dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. She also denied having any abdominal pain, nausea, vomiting, or diarrhea. Review of systems was positive for long-standing intermittent dysphagia with solid foods. Her medical history was notable for mild intermittent asthma, allergic rhinitis, and long-standing peripheral eosinophilia of unclear significance. Her medication list included rare meloxicam, daily ciclesonide inhaler, and albuterol inhaler as needed. She denied tobacco, alcohol, or recreational drug use. CORRECT ANSWERS: 1. e. 2. e. 3. c. 4. a. 5. a.

Saved by point of care echo.

A 40-year-old black male with a past medical history of sickle cell disease, cardiomyopathy, and pulmonary hypertension presents as a transfer from an outside facility to a tertiary care hospital for evaluation after a formal echocardiogram reported “biatrial enlargement and small cystic structure adjacent to the right atrium.” The patient arrived at the receiving hospital in acute severe distress with altered mental status, tachycardia, tachypnea, hypoxia, and hypotension with near agonal respirations on bilevel positive airway pressure. He was also noted to have bilateral jugular venous distention to the angle of mandibles and bilateral lower extremity edema. Given the acuity of the patient's condition, a bedside point-of-care (POC) ultrasound was done using the Rapid Ultrasound for Shock and Hypotension (RUSH) protocol. Bilateral lung slide was present with a bilateral A-line profile. Inferior vena cava (IVC) interrogation showed a markedly dilated non-distensible IVC. In the apical 4-chamber cardiac view, with color Doppler, it became obvious that there was a very large extracardiac cystic mass nearly completely compressing the right atrium (Video 1). Mitral valve inflow velocity was assessed via pulse wave Doppler and was found to demonstrate echocardiographic pulsus paradoxus (Figure 1). The emergency physician made the diagnosis of an extracardiac cystic mass compressing the right atrium causing pericardial tamponade rapidly at the bedside. A multidisciplinary team was mobilized by the emergency physician and the epicardial cyst was drained under ultrasound guidance in the emergency department resulting in 1300 cc of serous fluid with the restoration of the right atrium volume, normalization of the patient's vital signs, and return to his normal mental status. Pericardial tamponade occurs when there is an impairment of ventricular filling due to atrial compression by pericardial fluid or blood.1 Far more rarely, cardiac tamponade can be caused by extrinsic compression.2 Traumatic pericardial effusions typically occur rapidly and present as acute hemodynamic compromise in the setting of trauma. Medical causes of tamponade can be much more insidious given the usually slower accumulation of pericardial fluid. Pericardial tamponade presents typically as either cardiogenic or obstructive shock. Although physical exam findings such as Beck's triad, are often cited, echocardiography provides an invaluable tool in the detection of tamponade.3 In one case series, the sensitivity of the presence of all 3 components of Becks Triad was 0%, whereas any single element had a sensitivity 50%.4 Emergency physicians can rapidly diagnose pericardial tamponade with POC ultrasound and thus render lifesaving treatment, as in this case.